More than 60 million Americans travel to foreign countries each year. We crowd museums, explore remote hiking trails, and find all sorts of ways to put our health at risk. Travel-related illnesses and injuries have become more common than ever before, says Lin Chen, MD, director of the Travel Medicine Center at Mount Auburn Hospital in Cambridge, Mass. Whether they're traveling to a European city or a South American jungle, far too many travelers fail to take the necessary steps to protect themselves, she says. Experts in travel medicine are ramping up their efforts to improve the health of Americans overseas -- if only we can put down our guidebooks long enough to pay attention.

Several factors have made travel-related illnesses and injuries more common than ever before, Chen says. Americans have become increasingly interested in visiting corners of the world rife with exotic diseases and poor sanitation, and equipped with few health services. The travelers themselves have changed, too. "People are traveling at a younger age," she says. "Younger people tend to be less experienced and may not be as careful." Older patients, especially those in poor health, may be at increased risk for infections as well.

Health risks aren't limited to the Third World, says David Boulware, MD, associate director of global health programs at the University of Minnesota. Tourists tend to gather in places with lots of other tourists, setting up excellent opportunities to spread colds and the flu. Even in relatively "clean" countries, food can hold surprises. Boulware estimates that 5 to 10 percent of visitors to developed countries will come down with diarrhea during a two-week trip. In developing countries, the odds are about 30 to 50 percent.

Diarrhea is the price travelers everywhere pay for taking chances with food and water. In developed countries, travelers put themselves at risk by eating out at restaurants for most of their meals. Most restaurants are clean, but customers simply don't have as much control over freshness and hygiene as they do when they cook at home. All it takes is one cook with dirty hands to put a damper on a vacation.

"It's a real crapshoot," Boulware says.

In developing countries -- where cholera, dysentery, shigellosis, and other foodborne diseases could be on the menu -- travelers don't take nearly enough precautions at mealtime. A revealing Swiss study in the 1980s found that 98 percent of travelers to less developed countries made a potentially risky mistake with foods or beverages within the first three days. For all of the nasty germs out there, infections aren't even the most serious threat to travelers. According to the Centers for Disease Control and Prevention (CDC), Americans overseas are about 17 times more likely to die in a traffic accident than from an infectious illness. Again, the danger is especially great in developing countries, where streets tend to be crowded and chaotic.

No matter where you're traveling, doing what you can to stay healthy should be one of your top priorities. You won't get the most out of your trip if you pick up a bad bug -- or worse.

When traveling in developed countries, simply avoiding colds and the flu will go a long toward your goal of a healthy trip. If it's flu season, get a flu shot before traveling. Boulware recommends packing a bottle of hand sanitizer and using it often. When traveling, you aren't likely to have constant access to a sink, soap, and a clean towel, so a hand sanitizer is the next best option. Also it's a good idea to pack a travel kit, with bandages and over-the-counter medications.

Flu shots and sanitizers can be extremely valuable for less-developed destinations, but you'll have lots of other germs to worry about, too. If you haven't been vaccinated against hepatitis A -- a disease that spreads easily through contaminated food and water --consider getting one before you travel. A single shot will protect you for six months. Two shots given six months apart will protect you for life. (If you get one shot just before your trip, don't forget to get the second one after you get back.) Since hepatitis A vaccinations are now routinely given to children, you won't have any trouble finding a clinic that carries the vaccine. It's also a good idea to make sure you and your family members are up-to-date on your tetanus vaccines.

Depending on where you're traveling, you may need vaccinations or other treatments to protect yourself from diseases such as malaria or yellow fever. The risks aren't the same from one country to another. And within countries, some areas are much more disease-ridden than others.

That's why Chen recommends checking with the experts about which vaccinations you'll need. You can start by going to the CDC's Web site (wwwn.cdc.gov/travel/destinationList.aspx). It offers health information and vaccine recommendations for countries across the globe. She also recommends a visit to a travel health specialist, a doctor with particular training and experience in preparing people for trips abroad. Travel health experts have the knowledge to make tough calls.

If you aren't a good candidate for a yellow fever vaccine -- perhaps because of a weak immune system -- you may have to rethink your Amazon cruise or African safari. Depending on where you're headed, your travel doctor may also give you antibiotics to bring along in case of diarrhea. Because most vaccines take a while to kick in, you should schedule your appointment four to six weeks before your trip.

Even if you get every shot modern medicine has to offer, you still need to watch what you eat and drink while visiting countries lacking modern sanitation. The CDC offers this straightforward advice: "boil it, cook it, peel it, or forget it." ("That advice originates from the 17^th century, but it's still true," Boulware says.) In other words, don't trust tap water (including ice cubes) unless it has been boiled first.

Bottled water is usually safe, and you can trust any carbonated beverage. You should even brush your teeth with bottled water. Food should be served steaming hot, so skip the salad. In fact, skip raw fruits and vegetables completely unless you can peel them yourself. Meat and seafood should be fully cooked. Avoid food from street vendors; they don't always put a premium on hygiene.

Traffic accidents may be a fact of life in the big cities of the world, but you can protect yourself. At a minimum, wear seat belts whenever possible and use a helmet when riding a bicycle or motorcycle. Bone up on traffic rules in your destination, and don't drive faster than necessary. Keep your eyes open in every direction when crossing streets -- in some places, motorcycles, cars, and bicyclists can seemingly pop up from anywhere. If you hire a driver, don't hesitate to fire the person if his driving makes you anxious. For specific information about traffic hazards in a particular country, visit the Web site of the Association for International Road Travel, www.asirt.org.

Take along proof of health insurance when you travel, including your ID card and a claims form. Better still, consider buying extra travel insurance that will cover any emergencies that may come up on your trip. Medical travel insurance insures you are covered if you have an accident, become ill, or need hospitalization while living or traveling abroad. Many domestic health insurance plans don't cover medical care while you are abroad.

If you're in reasonably good health and are prepared to take precautions, no country in the world should be off-limits. You can visit those museums and hike those trails. With a little luck -- and the right preparation -- you just might come home feeling better than when you left.

-- Chris Woolston, MS, is a contributing editor to Consumer Health Interactive. A former staff writer for Hippocrates magazine, he has written for Health, Prevention, and other journals. He writes The Healthy Skeptic, a biweekly column in the Los Angeles Times. He is also the co-author of Generation Extra Large: Rescuing Our Children from the Epidemic of Obesity (Perseus paperback, 2006).

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First published June 19, 2008
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